Thursday, May 31, 2012

Just the other day I was asked about the risk of a 'staph' infection from working out a gym.

We investigated surfaces in our university gym for staphylococcal burden. The study was recently published in the American Journal of Infection Control. In brief, we were unable to identify MRSA on the gym surfaces sampled, however, we did find Staphylococcus aureus.

It is possible to acquire Staphylococcus aureus and MRSA in athletic facilities. The risk is probably small. The wiping down of gym surfaces after each use and attention to handwashing after exercise should mitigate the risk of colonization and infection. For information from the CDC on the prevention of MRSA in athletic facilities, click here.

The benefits of regular exercise far outweigh the risk of a gym-acquired staphylococcal infection so don't invoke the fear of contagion as an excuse for skipping a workout.

Wednesday, May 30, 2012

Here is a hot off the press article published in the Journal of Hospital Infection on the successful implementation of an infection prevention checklist. Nurse directed rounds with detailed infection prevention safety checklists were performed in operating rooms and hospital wards. By documenting adherence with infection prevention interventions, and by providing on-the-spot corrective education, a significant reduction in hospital acquired infections was observed.

For years, the science of infection prevention has studied and identified risk factors for hospital acquired in infections. The focus now, at least in part, is the implementation of risk reduction practices. Safety checklists serve to reinforce and ensure compliance with risk reduction interventions, making safety practices mandatory and not optional. Implementation science now provides empiric data that safety checklists work.

Important examples include:

The central line checklist to reduce the rate of catheter associated bloodstream infections. To access this seminal paper, click here.

The surgical safety checklist, to avoid errors and minimize morbidity and mortality in surgical populations, as reported in the New England Journal of Medicine.

An engaging read on the use of checklists in medicine can be found in Atul Gawande's Checklist Manifesto.

Tuesday, May 29, 2012

I often struggle to understand why colleagues fail to address end of life issues or stop aggressive treatments and surgeries when palliative care would be a better course of action. If one practices inpatient medicine, then end of life care is nearly inevitable.

This perspective, published in the NY Times, sheds light on the impact that death, dying and grief can have on a physician, and in turn on patient care.

A paper published in the Archives of Internal Medicine qualitatively explored the nature and impact of grief on oncologists. In addition to sadness, crying, loss of sleep and feelings of shame, grief can impact the physician's patient management decisions. Feelings of guilt and failure motivated some oncologists to provide more aggressive care, even when such care was medically futile. Denial and disassociation motivated other oncologists to avoid end of life discussions with the patient and the family, distancing themselves further as the time of death neared. The potential impact on patient care in undeniable, and the study's authors call for physician education on grief and coping not only during training, but as continuing education throughout their careers.

It is bad enough that malaria afflicts millions of people in impoverished areas. Now we are informed that low quality, ineffective antimalarials are being manufactured and sold to resource poor countries.

Here is a disturbing report published in The Lancet Infectious Diseases highlighting the issue of substandard or just simply counterfeit antimalarials, many of them being manufactured in India or China. The drugs were distributed in southeast Asia and sub-Saharan Africa. In southeast Asia, up to 36% of medications sampled were counterfeit.At present, no universal jurisdiction allows prosecution of international traders in falsified drugs.

The fatal consequences of counterfeit antimalarials are described in this article from the Smithsonian.

To quote the Lancet paper's authors, "Production and distribution of counterfeit antimalarials should be prosecuted as crimes against humanity."

Tuesday, May 22, 2012

Here is an article published in Academic Medicine on the effects of short-term, international service-learning trips on medical students.

The study cohort was small and consisted of thirteen 1st year medical students from the University of Michigan. By no means is this cohort representative of all medical student associated medical relief trips to developing countries. The findings, however, are intriguing.

Of the study participants, almost no students articulated issues such as social justice or disparities as motives for seeking international service-learning trips. Common expectations were acquisition of clinical skills and language competency. However, during a structured interview with formal reflection, an increased awareness of the complexities of global health delivery and the importance of partnership with local health authorities for sustainability and impact was evident.

Albeit of limited duration, short term medical relief trips can increase medical student awareness of global health, health disparities and social justice, particularly if formal reflection is structured into the experience.

We have frequently been asked why our work in Honduras is valuable to us. The answer, in part, is found here.

Short term medical relief trips are likely of greatest value for local communities when executed as a longitudinal, collaborative effort with local health authorities to meet the public health needs of a population. That is the focus of our Global Health and health Disparities Program.

The use of antibiotics can result in gastrointestinal upset and mild to severe diarrhea, includingC.difficile. Symptoms of diarrhea occur in as many as 30% of patients. There is mounting evidence that the use of probiotics (Lactobacillus species and Saccharomyces species) dosed concurrently with antibiotics may be beneficial in decreasing the the risk of antibiotic associated diarrhea by 30-50%.

This seems promising however data is lacking to best determine which patient populations would benefit most from adjunct probiotic therapy. Not all people suffer from diarrhea when on antibitotics.

When to 'pull the trigger' on probiotics remains an area of uncertainty and controversy. Until more data is available, perhaps probiotic therapy is best for patients requiring prolonged antibiotics (>2 weeks) who have a prior history of antibiotic associated diarrhea.

Tuesday, May 15, 2012

I am currently supervising a medical team at VCU Medical Center and am acutely aware of duty hour restrictions for residents (16 hour limit for interns) and resident workload (number of patients and number admissions per shift for an intern)

As with any intervention in medicine we should ask ourselves what evidence exists to support this? Here is a recent review article published in the American Journal of Medicine. In brief, in a nationally representative sample of internal medicine programs, the investigators found no significant association between resident workload and patient outcomes for common inpatient diagnoses

I am not opposed to work hour and workload limitations and feel that they may lead to a more humane training experience for resident doctors. At present, however, no robust data exists to support that these measures results in safer care.

Friday, May 11, 2012

Here is an article on the effectiveness of audible hand hygiene alerts upon entering a patient care area. The study was published in the American Journal of Infection Control.

Investigators in the UK utilized an electronic motion sensor–triggered audible hand hygiene reminder that was installed at hospital ward entrances. The alert played the following message: “Please clean your hands with hand rub dispensers when entering or exiting any clinical ward."

Three thousand hand hygiene opportunities were observed. Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P< .001).

It is encouraging to see an improvement in hand hygiene with a simple, electronic and automated intervention. The baseline hand hygiene of 7.6 % in the study ward is alarmingly low and an improvement to only 50% is also concerning. More work needs to be done there.

Tuesday, May 8, 2012

Here is a study published in Infection Control and Hospital Epidemiology and a related article in Infection Control Today of the impact of hospital acquired infections on hospital readmission.

Using multivariable modeling on a retrospective cohort of patients in a tertiary-care, academic hospital over a 7 year time frame, the investigators demonstrated that a positive clinical culture for MRSA,VRE or C.difficile 48 hours after admission (hospital acquired infection) was a associated with a 40% increased risk of hospital readmission.

This adds to the body of literature on the relevance and impact of hospital acquired infections. Additionally, this supports the rallying call for evidence based infection prevention efforts. However, a word of caution is in order. Not all hospital acquired infections are preventable.The goal of zero infections may not (yet) be attainable. If you are skeptical, read on here, from the research committee of the Society of Healthcare Epidemiology of America. In brief, knowledge gaps exists in pathogenesis, epidemiology, and infection prevention strategies. These are not insignificant.

Monday, May 7, 2012

I am back on the internal medicine ward service for the next 2 weeks, so will likely be blogging 'light' given the volume of patient care.

I came across an intriguing article last week titled 'Uncertainty in the application of contact precautions', in press in Clinical Infectious Diseases. The study authors distributed a voluntary, paper survey at a meet-the-professors session at the 2011 Infectious Diseases Society of America meeting in Boston.

There were a total of 34 respondents. A majority of the survey respondents used contact precautions for the care of patients colonized or infected with multi-drug resistant organisms. Only 38% of the participants believed that contact precautions , as currently practiced, prevents the transmission of drug resistant pathogens and 26% felt that they prevent the transmission of all pathogens. Last, 74% of respondents were concerned that contact precautions may cause harm. I have blogged about the adverse consequences of contact precautions before.

Of course, these 34 survey respondents are not representative of all infectious diseases specialists and hospital epidemiologists. The findings, however, highlight an important, ongoing concern, specifically that a knowledge gap exists on how to best apply contact precautions in different settings so as to maximize benefit while minimizing harm.

Thursday, May 3, 2012

I am currently researching and writing a review article on contact precautions and the use of gowns and gloves for the control of drug resistant pathogens.

One concept that I have explored is the negative impact of glove use on hand hygiene. Here is a provocative article titled Wearing gloves: the worst enemy of hand hygiene? Another article published in the American Journal of Infection Control, by the same lead author, investigated the impact of improved glove usage on hand hygiene. Quite simply, greater compliance with gloving does not necessarily result in improvements in hand hygiene. There are dirty hands in the gloves.

My opinion? The promotion of glove use must be accompanied by concurrent and ongoing hand hygiene education. In our controlled trial of universal gloving, hand hygiene adherence was sustained during universal gloving by ongoing hand hygiene education and adherence monitoring.

The message is rather simple: wash you hands before and after donning gloves. There are no shortcuts.

Wednesday, May 2, 2012

Here is a timely article published in Clinical Infectious Diseases on the reliability of central line associated bloodstream infections (CLABSIs) surveillance.

Overall, 114 patient records were reviewed by 18 infection prevention specialists, the majority of whom specified they followed National Healthcare Safety Network (NHSN) criteria. The overall agreement amongst infection preventionists by kappa was 0.42 (SE 0.06). Better agreement was observed with a simple laboratory-based definition with an average kappa of 0.55 (SE 0.05). The proportion of patient records that 18 reviewers reported with CLABSI ranged from 14% to 39% (overall mean 28% with a CV of 25%). Again when simple laboratory-based methods were applied to patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean 39%).

The findings are significant for several reasons. First, despite training, certification and the use of a standardized CLABSI definition, application can be nuanced and is subject to interpretation based on individual cases with complex clinical conditions. At play here is the concept of inter-observer reliability. This is not a new concept. Here is an interesting study highlighting how the assessment of chest x-rays for pneumonia can differ between radiologists.

More importantly, the above CLABSI finding calls into question the methodological limitation of publicly reporting hospital acquired bloodstream infections. Despite a standardized CLABSI definition, the reliability of surveillance to appears not be ideal for the public goal of inter-hospital comparisons.

Tuesday, May 1, 2012

Researchers from Ethiopia and the USA have reported that cockroaches can carry multi-drug resistant pathogens. The report is published in Antimicrobial Resistance and Infection Control.

A total of 400 Blatella germanica roaches were aseptically collected for five consecutive months. Pathogens such as Klebsiella oxytoca, Klebsiella pneumoniae, Citrobacter spp. Enterobacter cloacae, Citrobacter diversus, Pseudomonas aeruginosa, Enterobacter aeruginosa, Salmonella C1, Non Group A streptococcus, Staphylococcus aureus, Escherichia coli, Acinetobacter spp. and Shigella were isolated both from the roaches internal and external organs. Multi-drug resistance was seen in all organisms.

The fact that cockroaches carry pathogenic bacteria has been reported for many years and should not be surprising. Here is another recent publication on the proposed role of cockroaches as vectors of hospital acquired pathogens.

In my opinion, there are greater risk factors for hospital acquired infections, such as poor hand hygiene and the improper insertion and use of invasive devices. However, if you find yourself in a clinical setting with visible cockroaches, be concerned as this is a direct marker of ineffective pest control and a surrogate marker of poor infection prevention efforts.